Does preoperative prognostic nutrition index predict surgical site infection after spine surgery?

Impact of perioperative nutritional supplementation on outcomes of spine surgery: A systematic review and meta-analysis

OBJECTIVE

Malnutrition, characterized by a total serum lymphocyte count less than 1500 cells/mm³ and serum albumin levels below 3.5 g/dL, is linked to delayed wound healing and a higher incidence of surgical site infections (SSIs). This meta-analysis evaluates the impact of perioperative nutritional supplementation on clinical outcomes in spine surgery.

METHODS

A systematic review of the published literature was conducted. Outcomes of interest included postoperative complications such as wound complications, SSI, and deep vein thrombosis (DVT). Estimated blood loss, operative time, and duration of hospital stay were also investigated.

RESULTS

Five studies with 554 patients were included. A total of 221 patients (39.90 %) were in the intervention group, compared to 333 patients (60.10 %) in the control group. The intervention groups received nutritional supplementation at different timeframes, including preoperatively or postoperatively. A significantly lower rate of total complications (OR: 0.32, CI: [0.12, 0.89], p = 0.04) and wound-related complications (OR: 0.34, CI: [0.20, 0.60], p < 0.01) was observed in the intervention group when compared to the control group. A trend towards fewer SSIs was observed (OR: 0.35, CI: [0.02, 7.19], p = 0.39). There were also fewer DVT events in the intervention group (OR: 0.62, CI: [0.04, 8.90], p = 0.52).

CONCLUSIONS

Patients receiving perioperative nutritional supplementation had significantly lower overall and wound-related complication rates compared to patients who did not receive nutritional supplementation perioperatively. This analysis highlights the value of nutritional supplementation as part of the perioperative care and optimization efforts in patients undergoing spine surgery.

Prediction of postoperative SSIs and causative organisms in the spine by measuring trophic factors using preoperative serum markers

BACKGROUND

Surgical site infection (SSI) following spinal surgery, although rare, is a serious complication that affects patient outcomes. Identifying risk factors such as patient background, preoperative serum markers, and surgical factors is essential for effective screening and prevention measures. Therefore, this study aimed to verify whether preoperative patient conditions serve as predictors of post-spinal surgery infections and to determine the association between preoperative serum markers and infecting pathogen species.

METHODS

This single center retrospective study analyzed 427 patients who underwent spinal surgery at our hospital between November 2019 and September 2022. Data on patient demographics, comorbidities, preoperative blood tests, surgical factors, SSI occurrence, and causative organisms were collected. Logistic regression analysis was performed to identify independent predictors of SSI, and a subgroup analysis compared preoperative serum markers between superficial and intra-abdominal bacterial infections.

RESULTS

SSI occurred in 33 patients (7.7 %). Several factors showed significant differences between the SSI and non-SSI groups, including albumin (ALB), Albumin-Globulin Ratio (AGR), Prognostic Nutritional Index (PNI), C-Reactive Protein (CRP), CAR, D-dimer, and blood loss. Logistic regression analysis identified ALB as the only independent predictor of SSI (OR = 0.23, 95 % CI: 0.11-0.48, P < 0.001), with a cutoff value of <4.0 g/dL. Among SSI cases with identified pathogens, 17 were caused by skin commensal bacteria, while 7 were attributed to intra-abdominal comm-ensal bacteria. Subgroup analysis revealed that AGR and Lympocyte to Monocyte Ratio (LMR) were significantly higher in the intra-abdominal infection group than in the superficial infection group (P = 0.028 and P = 0.045, respectively).

CONCLUSION

Preoperative ALB levels serve as a crucial predictor of postoperative SSI in spinal surgery, with a cutoff value of <4.0 g/dL. Additionally, the type of bacterial infection (superficial vs. intra-abdominal) may be influenced by preoperative patient factors.

Explainable Machine Learning Models for Prediction of Surgical Site Infection After Posterior Lumbar Fusion Surgery Based on Shapley Additive Explanations

OBJECTIVE

This study aims to develop machine learning (ML) models combined with an explainable method for the prediction of surgical site infection (SSI) after posterior lumbar fusion surgery.

METHODS

In this retrospective, single-center study, a total of 1016 consecutive patients who underwent posterior lumbar fusion surgery were included. A comprehensive dataset was established, encompassing demographic variables, comorbidities, preoperative evaluation, details related to diagnosed lumbar disease, preoperative laboratory tests, surgical specifics, and postoperative factors. Utilizing this dataset, 6nullML models were developed to predict the occurrence of SSI. Performance evaluation of the models on the testing set involved several metrics, including the receiver operating characteristic curve, the area under the receiver operating characteristic curve, accuracy, recall, F1 score, and precision. The Shapley Additive Explanations (SHAP) method was employed to generate interpretable predictions, enabling a comprehensive assessment of SSI risk and providing individualized interpretations of the model results.

RESULTS

Among the 1016 retrospective cases included in the study, 36 (3.54%) experienced SSI. Out of the six models examined, the Extreme Gradient Boost model demonstrated the highest discriminatory performance on the testing set, achieving the following metrics: precision (0.9000), recall (0.8182), accuracy (0.9902), F1 score (0.8571), and area under the receiver operating characteristic curve (0.9447). By utilizing the SHAP method, several important predictors of SSI were identified, including the duration of indwelling jugular vein catheter, blood urea nitrogen levels, total protein levels, sustained fever, creatinine levels, triglycerides levels, monocyte count, diabetes mellitus, drainage time, white blood cell count, cerebral infarction, estimated blood loss, prealbumin levels, Prognostic Nutritional Index, low back pain, posterior fusion score, and osteoporosis.

CONCLUSIONS

ML-based prediction tools can accurately assess the risk of SSI after posterior lumbar fusion surgery. Additionally, ML combined with SHAP could provide a clear interpretation of individualized risk prediction and give physicians an intuitive comprehension of the effects of the model's essential features.

Unseen threats: Lumens 2.0 study reveals the hidden challenges of cleaning lumened surgical instruments

BACKGROUND

Surgical site infections can cause significant morbidity requiring lengthy antimicrobial treatment. Infections have been linked to surgical instruments with retained tissue and foreign debris, as the presence of blood or soil interferes with sterilization effectiveness. This study aimed to determine the prevalence of visible soil or debris inside instruments and evaluate the impact of recleaning efforts.

METHODS

Borescopes were used to inspect lumens of instruments used for orthopedic, neurologic, or ear-nose-throat procedures. Whenever visible soil or debris was observed, the instrument was recleaned up to 3 times and reinspected to assess the impact of additional cleaning.

RESULTS

Researchers performed 117 inspections (40 unique instruments, 77 reinspections). All instruments had complex lumens that impede access by brushes. Debris and discoloration or residues were observed inside 100% of instruments, with rusty patches in 95%. Some soil was removed by recleaning, but visible soil remained in most lumens and fragments of lint or brush bristles were visible upon repeat inspection.

CONCLUSIONS

Cleaning in accordance with the manufacturer's instructions was not effective for lumened surgical instruments. Solutions will require collaboration between infection prevention, sterile processing, and manufacturers to evaluate risk and develop strategies for improving processing outcomes.

Impact of the Prognostic Nutritional Index on Outcomes in Native Spine Infection

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The objective of this study was to determine if a baseline prognostic nutritional index (PNI) score could be used to predict outcomes in patients with native spine infections, including the need for operative intervention.

SUMMARY OF BACKGROUND DATA

Nutritional status is an important, potentially modifiable risk factor to consider in the native spine population. The PNI score is a tool that has demonstrated utility as a marker of preoperative nutritional status in patients undergoing surgery; however, it has not yet been studied in the context of native spine infection.

METHODS

Adult patients (≥18 y) with a diagnosis of spine infection from 2017 to 2022 were retrospectively identified. Native spine infection was defined as a diagnosis of spinal infection in the absence of prior spine surgery within 3 months of diagnosis. PNI was calculated using the equation: PNI=10×serum albumin (g/dL)+0.005 total lymphocyte count (/μL). Patients were stratified into high or low PNI groups based on their PNI being above or below the average, respectively.

RESULTS

There were 45 patients in the low PNI group and 56 patients in the high PNI group. Patients in the low PNI group were more likely to require surgery ( P =0.046), had more levels decompressed ( P =0.012), and were more likely to undergo two or more irrigation and debridement procedures ( P =0.016). Patients in the low PNI group were also less likely to be discharged home ( P =0.016). There was no difference in length of stay, inpatient complications, 90-day readmissions, 90-day ED visits, or 1-year reoperations between groups.

CONCLUSION

While postadmission outcomes and inpatient complications were similar across PNI groups, PNI on admission provides useful insight into the severity of infection and predicts the need for operative intervention in patients presenting with native spine infection.

Enhanced recovery pathway in adult patients with spinal deformity undergoing open thoracolumbar surgery

PURPOSE

The poor prognosis of adult patients with spinal deformity following long-segment spinal fusion surgery remains a major concern. Our study aims to investigate the impact of an Enhanced Recovery After Surgery (ERAS) protocol on the prognosis of adult patients with spinal deformity.

METHODS

This study focused on a retrospective review of a database of previous adult spinal deformity. Adult patients with spinal deformity who underwent long-segment fusion surgery from July 2016 to July 2022 were evaluated, from July 2016 to July 2019 for the pre-ERAS patient group and from July 2019 to July 2022 for the ERAS group. Demographic data, radiological sagittal parameters, and intraoperative data were collected from all patients. The length of hospital stay, postoperative complications, and 90-day readmission rates were compared between the two groups. Additionally, multivariate regression models were used to analyze the predictors of postoperative length of stay, postoperative complications, and 90-day readmission rates.

RESULTS

A total of 215 patients were included in this study, 102 patients in the pre-ERAS group and 113 patients in the ERAS group. Postoperative outcomes in the ERAS group included significantly lower postoperative length of stay (LOS) (13.09 ± 4.57 vs. 11.13 ± 4.16, P = 0.001); significantly lower rate of postoperative complications (52.0% vs. 29.2%, P < 0.001) and significantly lower 90-day readmission rates (14.7% vs. 6.19%, P = 0.040). Multivariate linear regression showed that fewer ERAS (P = 0.022), later drain placement (P = 0.027), and more complications (P = 0.002) were significantly associated with longer postoperative LOS. Multivariate logistic regression showed that fewer ERAS (P = 0.015) and later drain removal (P = 0.041) were significantly associated with more complications, and more ERAS (P = 0.009), earlier postoperative LOS (P = 0.020), and earlier urinary catheter removal (P = 0.034) were significantly associated with the 90-day readmission rates.

CONCLUSIONS

According to the results of our study, it is necessary to implement an ERAS protocol for adult patients with spinal deformity undergoing long-segment fusion surgery. The ERAS protocol is effective in reducing postoperative hospital length of stay, incidence of surgical complications, and 90-day readmission rates.

Epidemiology, Controversies, and Dilemmas of Perioperative Nutritional Risk/Malnutrition: A Narrative Literature Review

Current perioperative nutrition management is discouraging due to the under-recognition of clinical nutrition and the lagging development of clinical nutriology. This review aimed to identify and explore epidemiology, related adverse outcomes, controversies, and dilemmas of perioperative nutritional risk/malnutrition to call for further development of perioperative nutritional medicine. Databases including PubMed, Embase, Cochrane Library, Wanfang Database, China National Knowledge Infrastructure, China Biology Medicine disc, and Chongqing VIP Database were searched for articles published between January 1, 2014 and August 31, 2024 using the following MeSH terms: ("nutritional risk"[Title/Abstract] OR "malnutrition"[Title/Abstract] OR "undernutrition"[Title/Abstract]) AND ("surgery"[Title/Abstract] OR "surgical"[Title/Abstract] OR "operative"[Title/Abstract] OR "operation"[Title/Abstract]). The incidence of nutritional risk was in the 20% range in patients undergoing elective surgery, 54% in older adults, 44-70% in patients with tumors or major elective surgeries, and 50-55% in children. The incidence of malnutrition ranged from 11-77% in surgical patients. Nutrition-related perioperative adverse events included mainly infection, wound healing disorders, reoperation and unplanned readmission, prolonged hospital stay, mortality, perioperative neurocognitive dysfunction, and venous thrombosis. Current controversies and dilemmas in this field include the low rates of nutrition screening and medical nutrition therapy, numerous nutrition screening tools and malnutrition diagnostic criteria, no consensus on optimal assessment method, low level of evidence-based clinical nutrition research and lack of in-depth mechanistic studies, inconsistent timing of nutrition assessment, lack of reports for community hospitals, small hospitals, and low/middle-income countries or regions, and under-recognition of micronutrient malnutrition. It is, therefore, necessary for perioperative patients to undergo nutritional screening at the first outpatient visit before surgery and/or on admission. Perioperative nutritional management needs urgent attention and requires a multidisciplinary team, including anesthesia, nursing, nutrition, and surgery.

Prognostic nutritional index and naples prognostic score as biomarkers for the prognosis of incisional wound healing after thoracolumbar tuberculosis surgery

OBJECTIVES

This study aimed to evaluate and compare the clinical predictive value of prognostic nutritional index (PNI) and naples prognostic score (NPS) as biomarkers for the prognosis of incisional wound healing in patients who underwent thoracolumbar tuberculosis surgery through the posterior approach.

METHODS

From January 2019 to October 2021, a total of 124 patients with thoracolumbar tuberculosis who underwent posterior approach debridement and internal fixation were included in this study. We retrospectively analyzed the clinical data, including PNI and NPS. They were divided into poor wound healing (PWH) and non-PWH groups according to whether PWH developed after the operation. And according to the receiver operating characteristic curve, patients were divided into two groups through the threshold value. Risk factors were found using logistic regression analysis.

RESULTS

The unfavorable outcome group had lower hemoglobin, serum albumin, Pre-albumin, PNI, and higher estimated blood loss, instrumented segments, neutrophil count, and NPS (P < 0.05). Both PNI and NPS were strongly correlated with PWH (r = 0.373, P < 0.05; r = -0.306, P < 0.05, respectively). The area under the curve (AUC) of PNI for predicting unfavorable outcomes was 0.764 (95% CI 0.662-0.865, P < 0.001), which was similar to NPS (0.808, 95% CI: 0.719-0.897, P < 0.001). Multivariate stepwise logistic regression analysis showed that PNI, NPS, the neutrophil count, the level of serum albumin, and the number of instrumented segments were independent risk factors for PWH.

CONCLUSION

Both PNI and NPS might be novel independent biomarkers and predictors of poor outcomes in incisional wound healing after STB surgery.

Preoperative Nutritional Status Screened by MNA-SF Predicts Major Complications in Elderly Patients Undergoing Lumbar Fusion Surgery

Purpose

To investigate the role of Mini Nutritional Assessment-Short Form (MNA-SF) in predicting postoperative complications in older patients (≥75 years) undergoing lumbar fusion surgery.

Patients and Methods

Patients who had undergone posterior lumbar fusion surgery between June 2019 and September 2021 were enrolled. Those with an MNA-SF score of 12 or higher were categorized as the Nourished group, while those with a score less than 12 were placed in the Malnutrition-Risk group. Preoperative, intraoperative, and postoperative variables between groups were compared. Patients were then re-classified based on the presence of major complications, univariate analysis and multivariate logistic regression was used to identify risk factors for major complications.

Results

A total of 240 patients were enrolled, with 182 in the Nourished group and 58 in the Malnutrition-Risk group. The Malnutrition-Risk group exhibited a higher incidence of major complications (46.6% vs 23.1%, p = 0.001) and comprehensive complications index (18.42 ± 18.00 vs 12.65 ± 15.87, p = 0.021), Oswestry Disability Index (27.52 ± 23.44 vs 20.45 ± 20.42, p = 0.029) and longer recovery times (12.53 days vs 10.15 days, p =0.033). Length of stay (LOS) were also increased in the Malnutrition-Risk group (19.22 ± 10.67 vs 16.04 ± 7.69, p = 0.014). Multiple regression analysis identified nutritional risk and malnutrition, as assessed by MNA-SF, as independent factors associated with postoperative major complications (OR 2.81, 95% CI 1.42-5.53, p = 0.003).

Conclusion

Preoperative nutritional risk or malnutrition is an independent risk factor for major complications among older patients undergoing posterior lumbar fusion surgery. The MNS-SF emerges as a convenient and effective tool for promptly screening the nutritional status of older patients, prompting subsequent nutritional evaluation or intervention before surgery.

Perioperative complications in patients aged ≥85 years undergoing spinal surgery: a retrospective comparative study of pre-old and old patients in Japan

STUDY DESIGN

A retrospective comparative study.

PURPOSE

To compare the characteristics of perioperative complications in patients aged ≥85 years with those of younger patients undergoing similar spine surgery and examine factors associated with perioperative complications and clinical outcomes among patients aged ≥85 years.

OVERVIEW OF LITERATURE

The risk factors for perioperative complications and their effect on outcomes in patients aged ≥85 years remain unclear. Furthermore, no study has compared younger patients with similar surgeries and condition with those aged ≥85 years.

METHODS

The study included patients aged ≥65 years who underwent spinal surgeries. The patients aged ≥85, 75-84, and 65-74 years were categorized into the super-old, old, and pre-old groups, respectively. The differences in perioperative age-related complications were compared among the three groups while matching for surgical procedures and general conditions (study 1). Furthermore, preoperative and intraoperative factors were examined for perioperative complications in the super-old group (study 2). Complications were categorized into surgical site and systemic complications.

RESULTS

The analysis included 44 patients from each group. In study 1, the total complication rates were 40.9%, 25%, and 18.2% of the super-old, old, and pre-old groups, respectively. Differences in complication rates were observed between the super-old and pre-old groups (p=0.011). In study 2, 58 patients from the super-old group were analyzed. Surgical site complications were significantly associated with longer surgical duration (p=0.02) and more estimated blood loss (p=0.003). Systemic complications were significantly associated with previous cerebrovascular disease (p=0.014), preoperative motor deficit (p=0.023), and emergency case (p=0.006) and negatively associated with diabetes mellitus (p=0.048).

CONCLUSIONS

Perioperative complications increased with advancing age in the super-old, old, and pre-old groups. The complication type is associated with specific background factors; therefore, determining them may help prevent perioperative complications.

Preoperative Serum Albumin and TLC as Predictors of Postoperative Complications in Spine Surgery

STUDY DESIGN

Narrative review.

PURPOSE

To investigate the state of literature regarding serum albumin and total lymphocyte count and their associations with postoperative complications after spine surgery.

METHODS

Comprehensive search of the PubMed database was performed to find relevant articles addressing preoperative serum albumin, total lymphocyte count, or their respective composite scores and their associations with postoperative complications after spine surgery.

SUMMARY OF BACKGROUND DATA

Serum albumin level is frequently cited as a marker of patient nutritional status. Total lymphocyte count has more recently gained attention in the literature for similar reasons. Identification of modifiable preoperative patient risk factors for postoperative complications such as malnutrition may help minimize the incidence of postoperative complications.

RESULTS

Review of the literature revealed 10 studies that discussed the association between preoperative hypoalbuminemia and postoperative complications. Five studies examined the relationship between either prognostic nutritional index (PNI), controlling nutritional status (CONUT), or both and postoperative complications after spine surgery. Preoperative hypoalbuminemia, low PNI, and high CONUT scores were associated with increased risk of postoperative complications after spine surgery.

CONCLUSIONS

Preoperative malnourishment is a modifiable patient factor that is associated with an increased risk of postoperative complications after spine surgery.

Effects of sarcopenia and nutritional status on surgical outcomes for metastatic spinal tumors: In the perspective of peri-operative complications and performance improvement

BACKGROUND

With the advancement of cancer treatment, appropriate treatment for musculoskeletal problems is becoming more important as it extends the patient's lifespan and improves the quality of life. In surgical treatment for metastatic spine tumors (MST), various efforts are being considered to obtain a good prognosis. The purposes of this study are to analyze prognostic factors for postoperative ambulation and perioperative complications in patients surgically treated for MST with neurologic symptoms.

METHODS

Seventy five cases of patients who underwent surgery for MST with neurologic symptoms were enrolled between December 2016 and January 2023. Postoperative ambulatory function and medical complications were assessed for each patient in this study. The endpoint of ambulatory function was defined as the best function among entire periods of follow-up outpatient visits. We defined the improvement of ambulatory function as improvement in Eastern Cooperative Oncology Group (ECOG) scale. For complications, we applied complication classification system for orthopaedic surgery. Perioperative complications were defined as those requiring changes of treatment compared with routine postoperative treatment during patient's admission. Confirmed complications included expire, delirium, urinary tract infection (UTI), pneumonia, sepsis, bacteremia, acute kidney injury (AKI), chylothorax. Prognostic factors were collected and analyzed for relationship by logistic regression.

RESULTS

Of the 75 cases, postoperatively 42 (56%) cases of patients were improved in Nurick grade, 36 (48%) cases of patients in ECOG performance. And 21 (28%) cases of patients were treated in intensive care unit (ICU) and 15 (20%) cases of patients suffered from major perioperative complications. Regression analysis showed that clinical factors such as ECOG, psoas muscle index (PMI) and prognostic nutritional index (PNI) were related to the improvement of ambulatory function and incidence of perioperative complications. On multivariate analysis, improvement of ambulatory function was associated with PMI (p = 0.014) and incidence of perioperative complications was associated with PNI (p = 0.045).

CONCLUSIONS

Preoperative nutritional status and sarcopenia are related factors in the outcome of surgical treatment for MST, and preoperative efforts to improve these may be a way to obtain better clinical results.

Perioperative Nutritional, Functional, and Bone Health Optimization in Spine Surgery: A National Investigation of Spine Surgeons' Perceptions and Practices

INTRODUCTION

While perioperative nutritional, functional, and bone health status optimization in spine surgery is supported with ample evidence, the implementation and surgeon perception regarding such efforts in clinical practice remain largely unexplored. This study sought to assess the current perception of spine surgeons and implementation regarding the nutritional, functional status, and bone health perioperative optimization.

METHODS

An anonymous 30-question survey was distributed to orthopaedic spine fellowship and neurosurgery program directors identified through the North American Spine Society and American Association of Neurological Surgeons contact databases.

RESULTS

The questionnaire was completed by 51 surgeon survey respondents. Among those, 62% reported no current formal nutritional optimization protocols with 14% not recommending an optimization plan, despite only 10% doubting benefits of nutritional optimization. While 5% of respondents perceived functional status optimization as nonbeneficial, 68% of respondents reported no protocol in place and 46% noted a functional status assessment relying on patient dependency. Among the respondents, 85% routinely ordered DEXA scan if there was suspicion of osteoporosis and 85% usually rescheduled surgery if bone health optimization goals were not achieved while 6% reported being suspicious of benefit from such interventions.

CONCLUSION

While most responding spine surgeons believe in the benefit of perioperative nutritional and functional optimization, logistical and patient compliance challenges were noted as critical barriers toward optimization. Understanding surgeon perception and current practices may guide future efforts toward advancement of optimization protocols.

Surgical Apgar Score and Controlling Nutritional Status Score can be predictors of major postoperative complications after spine surgery

Assessing intraoperative hemodynamics with Surgical Apgar Score (SAS) and preoperative nutritional status with the Controlling Nutritional Status (CONUT) score are said to be useful to predict postoperative complications in many surgical services, but little is reported in the field of spinal surgery. The purpose of this study was to assess the utility of SAS and the CONUT score for predicting the risk of major postoperative complications after spinal surgery. We included 659 people who undergone spinal surgery in our institute in eight consecutive years. The occurrence of postoperative major complications was investigated. Background clinical information, surgical information including the SAS and the CONUT score, and the length of postoperative hospital stay were collected. The risk factors of postoperative complications were assessed statistically. Complications occurred in 117 cases (17.8%). The multivariate analysis showed that history of diabetes mellitus (odds ratio [OR] 1.81: P = 0.035), coronary disease (OR 3.33; P = 0.009), American Society of Anesthesiologists Physical Status (OR 1.71; P = 0.025), use of instruments (OR 2.07; P = 0.026), operation time (OR 1.30; P < 0.001), SAS (OR 0.59; P < 0.001), and CONUT (OR 1.34; P < 0.001) were independent risk factors of major complications after spinal surgery. Assessing the intraoperative hemodynamics with SAS and preoperative nutritional status with the CONUT score was useful in predicting major postoperative complications after spinal surgery. People who are detected as high risked people should be managed carefully after spinal surgery.

Prediction models for risk assessment of surgical site infection after spinal surgery: A systematic review

Background

Spinal surgeries are a common procedure, but there is significant risk of adverse events following these operations. While the rate of adverse events ranges from 8% to 18%, surgical site infections (SSIs) alone occur in between 1% and 4% of spinal surgeries.

Methods

We completed a systematic review addressing factors that contribute to surgical site infection after spinal surgery. From the included studies, we separated the articles into groups based on whether they propose a clinical predictive tool or model. We then compared the prediction variables, model development, model validation, and model performance.

Results

About 47 articles were included in this study: 10 proposed a model and 5 validated a model. The models were developed from 7,720 participants in total and 210 participants with SSI. Only one of the proposed models was externally validated by an independent group. The other 4 validation papers examined the performance of the ACS NSQIP surgical risk calculator.

Conclusions

While some preoperative risk models have been validated, and even successfully implemented clinically, the significance of postoperative SSIs and the unique susceptibility of spine surgery patients merits the development of a spine-specific preoperative risk model. Additionally, comprehensive and stratified risk modeling for SSI would be of invaluable clinical utility and greatly improve the field of spine surgery.

Do nutritional assessment tools (PNI, CONUT, GNRI) predict adverse events after spinal surgeries? A systematic review and meta-analysis

BACKGROUND

Nutritional assessment tools are used to predict outcomes in cancer. However, their utility in patients undergoing spinal surgery is unclear. This review examined if prognostic nutritional index (PNI), controlling nutritional status (CONUT), and geriatric nutritional risk index (GNRI) can predict adverse events after spinal surgeries.

METHODS

PubMed, CENTRAL, Scopus, and Embase were screened by two reviewers for relevant studies up to 26th January 2024. The primary outcome of interest was total adverse events after spinal surgery. Secondary outcomes were surgical site infections (SSI) and mortality.

RESULTS

14 studies were included. Meta-analysis showed that while reduced PNI was not associated with an increased risk of SSI there was a significant association between PNI and higher risk of adverse events. Meta-analysis showed that high CONUT was not associated with an increased risk of complications after spinal surgeries. Pooled analysis showed that low GNRI was associated with an increased risk of both SSI and adverse events. Data on mortality was scarce.

CONCLUSIONS

The PNI and GNRI can predict adverse outcomes after spinal surgeries. Limited data shows that high CONUT is also associated with a non-significant increased risk of adverse outcomes. High GNRI was predictive of an increased risk of SSI. Data on mortality is too scarce for strong conclusions.

Prognostic Nutritional Index and the Risk of Postoperative Complications After Spine Surgery: A Meta-Analysis

BACKGROUND

A low prognostic nutritional index (PNI) may reflect malnutrition, which has been associated with poor prognosis in patients with various clinical conditions. The aim of the systematic review and meta-analysis was to investigate the association between preoperative PNI and risk of postoperative complications in adult patients after spine surgery.

METHODS

An extensive search was conducted on PubMed, Embase, and Web of Science to identify relevant cohort studies. Random-effects models were employed to combine the findings, taking into account the potential influence of heterogeneity.

RESULTS

Ten cohort studies involving 3,249 patients receiving spine surgeries were included. Pooled results showed that a low preoperative prognostic nutritional index (PNI) was associated with an increased risk of overall postoperative complications in these patients (odds ratio [OR]: 1.82, 95% confidence interval [CI]: 1.42 to 2.34, P < 0.001; I2 = 49%). Specifically, a preoperative malnutrition as evidenced by a low PNI was associated with a higher incidence of postoperative delirium (OR: 2.36, 95% CI: 1.52 to 3.66, P < 0.001; I2 = 38%) and surgical site infection (OR: 1.41, 95% CI: 1.15 to 1.73, P = 0.001; I2 = 0%). Sensitivity analyses by excluding one study at a time did not significantly change the results (P all <0.05).

CONCLUSIONS

A preoperative low prognostic nutritional index (PNI) may be a risk factor of increased incidence of overall postoperative complications, postoperative delirium, and surgical site infection in adult patients after spine surgeries.

Effect of drain placement in short-level spinal surgery on postoperative wound infection: A meta-analysis

In the meta-analysis, we evaluated the efficacy of placing drainage channels following single- or double-level spine surgery in order to decrease the incidence of postoperative injury. We conducted the analysis with the help of four databases: PubMed, Embase, Cochrane Library and Web of Science. A review of related studies was carried out after evaluating the quality of the literature against the classification and exclusion criteria set for the trial. Calculation of 95% CI, OR and MD was performed with fixed-effect models. A meta-analysis of the data was carried out with RevMan 5.3. Meta-analyses of randomized controlled trial (RCT) did not indicate that there were a statistically significantly different incidence of postoperative wound infections among those who received drainage compared to those who did not receive drainage (OR, 2.29; 95% CI, 0.50, 10.41 p = 0.28). Moreover, there were no statistically significant differences in post-operation hematoma (OR, 1.20; 95% CI, 0.27, 5.28 p = 0.81) and visual analogue scale score (MD, -0.01; 95% CI, -1.34, 1.33 p = 0.99). Thus, placing drainage in short-levels of spine operation did not significantly influence the outcome of postoperative wound complications. Nevertheless, because of the limited sample size chosen for this meta-analysis, caution should be exercised when treating these data. More high-quality RCT trials with a large number of samples are required to confirm the findings.

Role of Pre-Operative Nutrition Status on Surgical Site Infection After Posterior Lumbar Interbody Fusion: A Retrospective Study

Background: A retrospective case-control study to determine the role of pre-operative systemic and local nutritional factors on patients developing a surgical site infection (SSI) after posterior lumbar interbody fusion (PLIF). Surgical site infection after PLIF remains a substantial cause of morbidity. The literature demonstrates the prognosis of surgical patients is associated with pre-operative nutritional status that not only includes systemic nutritional factors, such as prognostic nutritional index (PNI), body mass index (BMI), and serum albumin, but also local nutritional factors, such as subcutaneous fat thickness at the surgical site, including absolute fat thickness and relative fat thickness. However, the role of pre-operative nutrition status in SSI after PLIF surgery remains unclear. Patients and Method: A retrospective review was performed on a consecutive cohort of 766 consecutive adult patients who underwent PLIF surgery for lumbar degenerative conditions between 2020 and 2021 at Second Xiangya Hospital. Previously identified risk factors as well as systemic and local nutritional factors nutritional factors were collected. Results: Among the 766 patients, 38 had post-operative SSI including 15 superficial SSI and 23 deep SSI. Univariable analysis showed that body weight, BMI, PNI, serum albumin, and relative fat thickness differed between the SSI and non-SSI groups. Multivariable logistic regression analysis showed that pre-operative PNI and relative fat thickness were independently associated with SSI after PLIF surgery. Conclusions: Lower pre-operative PNI and higher relative fat thickness are independent risk factors for developing deep SSI after PLIF.

Prognostic Nutritional Index Is a Predictive Marker for Health-Related Quality of Life in Patients with Adult Degenerative Scoliosis

Our aim was to ascertain whether the prognostic nutritional index (PNI), could predict the health-related quality of life (HRQOL) in patients with adult degenerative scoliosis (ADS) undergoing corrective surgery. We conducted a retrospective analysis of consecutive patients diagnosed with ADS between January 2013 and June 2021. Three nutritional parameters were employed for analysis (PNI, anemia, and hypoalbuminemia). We utilized the Scoliosis Research Society-22 (SRS-22) questionnaire and the Oswestry Disability Index (ODI) questionnaire to assess clinical outcomes. Following the epidemiology guidelines, we presented results from three different models: the crude model, minimally adjusted model, and fully adjusted model. A total of 316 ADS patients were included in the statistical analysis. There was no significant difference in sagittal plane radiographic parameters between the two groups. After adjusting for important confounding factors, PNI was an independent predictor of postoperative HRQOL. Specifically, for each one-unit increase in PNI, there was an approximately 20% higher likelihood of patients achieving a better HRQOL. Furthermore, we did not observe an association between hemoglobin levels or albumin levels and HRQOL. In this study, PNI has been demonstrated to be correlated with the postoperative HRQOL in patients with ADS undergoing corrective surgery.

Impact of spinal surgery on locomotive syndrome in patients with lumbar spinal stenosis in clinical decision limit stage 3: a retrospective study

BACKGROUND

Locomotive syndrome (LS) is characterized by reduced mobility. Clinical decision limit (CDL) stage 3 in LS indicates physical frailty. Lumbar spinal canal stenosis (LSS) is one of the causes of LS, for which lumbar surgery is considered to improve the CDL stage. This study aimed to investigate the efficacy of lumbar surgery and independent factors for improving the CDL stage in patients with LSS.

METHODS

This retrospective study was conducted at the Department of Orthopaedic Surgery at our University Hospital. A total of 157 patients aged ≥ 65 years with LSS underwent lumbar surgery. The 25-Question Geriatric Locomotive Function scale (GLFS-25) was used to test for LS, and the Timed Up and Go test (TUG) was used to evaluate functional ability. Lower limb pain was evaluated using a visual analog scale. Patients with at least one improvement in the CDL stage following lumbar surgery were included in the improvement group. Differences in lower limb pain intensity between the groups were evaluated using the Wilcoxon rank-sum test. The Spearman's rank correlation coefficient was used to determine correlations between Δ lower limb pain and Δ GLFS-25. Logistic regression analysis was used to identify factors associated with improvement in LS.

RESULTS

The proportion of patients with improved CDL stage was 45.1% (improvement/non-improvement: 32/39). Δ Lower limb pain was significantly reduced in the improvement group compared with that in the non-improvement group (51.0 [36.3-71.0] vs 40.0 [4.0-53.5]; p = 0.0107). Δ GLFS-25 was significantly correlated with Δ lower limb pain (r = 0.3774, p = 0.0031). Multiple logistic regression analysis revealed that TUG and age were significantly associated with improvement in LS (odds ratio, 1.22; 95% confidence interval: 1.07-1.47).

CONCLUSIONS

Lumbar surgery effectively improved the CDL stage in patients with LSS. In addition, TUG was an independent factor associated with improvement in the CDL.

Nutritional and Inflammatory Indices and the Risk of Surgical Site Infection After Fragility Hip Fractures: Can Routine Blood Test Point to Patients at Risk?

Background: Surgical site infection (SSI) after fragility hip fracture (FHF) surgery is associated with increased morbidity and mortality. We aim to utilize several established nutritional and inflammatory indices to characterize patients at risk. Patients and Methods: A retrospective cohort study of patients 65 years and older, who underwent surgery following FHFs between January 2012 and June 2020. Those patients who presented with post-operative infection in the year after surgery were compared with patients who did not. The primary outcomes were serum albumin, protein energy malnutrition (PEM), albumin to globulin ratio, prognostic nutritional index (PNI), the systemic immune inflammation index, platelet to lymphocyte ratio, neutrophil to lymphocyte ratio, and body mass index. Results: A total of 1,546 patients, ages 82.4 ± 7.7, were included; 55 of whom presented with SSI. Demographics and comorbidities were similar. Anticoagulation treatment was more prevalent in the infected group (32.7% vs. 13.9%, p < 0.001) as were intra-capsular fractures (60% vs. 42.9%, respectively; p = 0.012). Of all indices estimated, only the PNI and the PEM were found to differ significantly (44.7 ± 9.6 and 26.1% vs. 49.4 ± 17.3 and 13.6% for the study and control groups respectively; p = 0.002 and 0.027). A logistic regression model was calculated to evaluate the contribution of fracture type and anticoagulation treatment as possible confounders. Both indices were found to be significant for infection after regression odds ratio, 2.25 for PEM; (95% confidence interval [CI], 1.089-4.344) and odds ratio, 0.97 for PNI (95% CI, 0.937-0.996). Conclusions: The PNI and the PEM were found to correlate with infection risk after FHF surgery. As both can be easily calculated from an accessible blood test, we recommend their routine use as a screening tool for tailored management of patients at risk for SSI.

Phase angle is related to physical function and quality of life in preoperative patients with lumbar spinal stenosis

Lumbar spinal stenosis (LSS) can interfere with daily life and quality of life (QOL). Evaluating physical function and QOL and helping patients to improve is the focus of rehabilitation. Phase angle (PhA) assessment is widely used to measure body composition and is considered an indicator of physical function and QOL. This study investigated the relationship between PhA and physical function, physical activity, and QOL in patients with LSS. PhA, handgrip strength, walking speed, Timed Up and Go test (TUG), Life Space Assessment (LSA), Prognostic Nutritional Index (PNI), Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), and EQ-5D were assessed and statistically analyzed. The study included 133 patients with LSS. Multiple regression analysis of PhA adjusted for age, sex, and body mass index (Model 1) and for Model 1 + PNI (Model 2) showed significant correlations (P < 0.05) with handgrip strength, walking speed, TUG, and LSA. Regarding QOL, PhA was significantly correlated (P < 0.05) with lumbar function in JOABPEQ. PhA was associated with physical function and QOL in patients with LSS and might be a new clinical indicator in this population.

A meta-analysis of risk factors for non-superficial surgical site infection following spinal surgery

BACKGROUND

Surgical site infection (SSI) is the most common complications in spinal surgery. In SSI, non-superficial surgical site infections are more likely to result in poor clinical outcomes. It has been reported that there are multiple factors contributing to postoperative non-superficial SSI, but still remains controversial. Therefore, the aim of this meta-analysis is to investigate the potential risk factors for non-superficial SSI following spinal surgery.

METHODS

A systematic database search of PubMed, Embase, Web of Science, Cochrane Library and Clinical Trials was performed for relevant articles published until September 2022. According to the inclusion and exclusion criteria, two evaluators independently conducted literature screening, data extraction and quality evaluation of the obtained literature. The Newcastle-Ottawa Scale (NOS) score was used for quality evaluation, and meta-analysis was performed by STATA 14.0 software.

RESULTS

A total of 3660 relevant articles were initially identified and 11 articles were finally included in this study for data extraction and meta-analysis. The results of meta-analysis showed that the diabetes mellitus, obesity, using steroids, drainage time and operative time were related to the non-superficial SSI. The OR values (95%CI) of these five factors were 1.527 (1.196, 1.949); 1.314 (1.128, 1.532); 1.687(1.317, 2.162); 1.531(1.313, 1.786) and 4.255(2.612, 6.932) respectively.

CONCLUSIONS

Diabetes mellitus, obesity, using steroids, drainage time and operative time are the current risk factors for non-superficial SSI following spinal surgery. In this study, operative time is the most important risk factor resulting in postoperative SSI.

Frequency and Associated Factors of Postoperative Wound Dehiscence in Posterior Cervical Spine Surgery

OBJECTIVE

Wound dehiscence after cervical spine surgery is a well-known complication that can be a challenge for spine surgeons to manage, especially in cases of exposed implants. However, few studies have focused primarily on this phenomenon in cervical spine surgery to date. This investigation sought to determine the frequency of wound dehiscence following posterior cervical spine surgery and identify patient-based risk factors.

METHODS

The medical data of 405 consecutive patients (290 male and 115 female; mean age: 68.9 years) who underwent posterior cervical spine surgery were retrospectively examined. Logistic regression models were employed to examine the prevalence, characteristics, and risk factors of postoperative wound dehiscence.

RESULTS

We observed that 5.2% of cervical spine surgery patients experienced procedural postoperative wound dehiscence. In comparisons of dehiscence and non-dehiscence groups, significant differences were found for posterior instrumented fusion (81.0% vs. 45.3%; P < 0.01), extended T1 fusion (57.1% vs. 12.8%; P < 0.01), occipitocervical fusion (19.0% vs. 6.2%; P = 0.048), fused intervertebral levels (4.0 vs. 1.5; P < 0.01), surgical time (246 minutes vs. 165 minutes; P < 0.01), blood loss volume (228 mL vs. 148 mL; P = 0.023), and dialysis (14.3% vs. 1.8%; P = 0.011). Multivariate analysis identified extended T1 fusion and dialysis to be significantly associated with wound dehiscence with odds ratios of 5.82 and 10.70, respectively.

CONCLUSIONS

The observed frequency of postoperative wound dehiscence in cervical spine surgery was 5.2%. As extended T1 fusion and dialysis may increase the risk of dehiscence after surgery, patients who display such risk factors may require additional observation and care.

Perioperative Nutritional Supplementation Decreases Wound Healing Complications Following Elective Lumbar Spine Surgery: A Randomized Controlled Trial

BACKGROUND

The prevalence of malnutrition in patients undergoing lumbar spine surgery ranges from 5% to 50% and is associated with higher rates of surgical site infections, medical complications, longer lengths of stay, and mortality.

PURPOSE

To determine if perioperative nutritional intervention decreases wound healing complications in patients undergoing lumbar spine surgery.

STUDY DESIGN/SETTING

A prospective randomized controlled trial.

MATERIALS AND METHODS

Patients aged 55+ undergoing elective primary lumbar surgery were included. Patients with a preoperative albumin<3.5 g/dL were defined as malnourished. Intervention group received nutritional supplementation (protein shake) twice daily from postoperative day 0 to two weeks postdischarge. Control group was instructed to continue regular daily diets. Primary outcomes included minor in-hospital complications (wound drainage, electrolyte abnormalities, hypotension, ileus, deep venous thrombus) and wound healing complications within 90 days. Secondary outcomes included 90-day emergency room visits, readmissions, and return to the operating room. Baseline data were compared between groups using means comparison tests. Multivariable analysis evaluated association of outcomes with nutritional supplementation. Subanalysis of malnourished patients assessed effects of nutritional supplementation on outcomes.

RESULTS

One hundred three patients were included. Thirty-seven (35.9%) were considered malnourished preoperatively. Forty-six (44.7%) received nutritional intervention and 57 (55.3%) served as controls. Adjusted analysis found patients receiving supplementation had lower rates of in-hospital minor complications (2.1% vs. 23.2%, P <0.01), and perioperative wound healing complications (3.4% vs. 17.9%, P <0.05). Subgroup analysis of 37 malnourished patients demonstrated that malnourished patients who received perioperative nutritional supplementation had lower rates of minor complications during admission (0.0% vs. 34.4%, P =0.01) and return to the operating room within 90 days (0.0% vs. 12.4%, P =0.04).

CONCLUSIONS

Over one third of patients undergoing lumbar surgery were malnourished. Nutritional supplementation during the two-week perioperative period decreased rates of minor complications during admission and wound complications within 90 days. Malnourished patients receiving supplementation less often returned to the operating room. To our knowledge, this is the first study to investigate the effects of perioperative nutritional intervention on wound healing complications for patients undergoing elective lumbar spine surgery.

LEVEL OF EVIDENCE

I.

Association between hypoalbuminemia and complications after degenerative and deformity-correcting spinal surgeries: A systematic review and meta-analysis

Objective

The current review was designed to explore if hypoalbuminemia is associated with increased complications in patients undergoing spinal degenerative and deformities surgeries.

Methods

The search for eligible studies was conducted on the databases of PubMed, Embase, Web of Science, and CENTRAL up to 20th June 2022. Complication rates were pooled to obtain odds ratio (OR) and 95% confidence intervals.

Results

Thirteen studies were included. We found that hypoalbuminemia was significantly associated with increased risk of all complications (OR: 2.72 95% CI: 2.04, 3.63 I ²= 58% p < 0.00001), mortality (OR: 7.73 95% CI: 3.81, 15.72 I ²= 0% p < 0.00001), revision surgery (OR: 3.15 95% CI: 1.53, 6.48 I ²= 87% p = 0.002), readmissions (OR: 1.96 95% CI: 1.29, 2.98 I ²= 23% p = 0.02), surgical site infections (OR: 2.97 95% CI: 1.90, 4.63 I ²= 38% p < 0.00001), wound complications (OR: 2.31 95% CI: 1.17, 4.56 I ²= 48% p = 0.02), pulmonary complications (OR: 3.74 95% CI: 2.66, 5.26 I ²= 0% p < 0.00001), renal complications (OR: 3.04 95% CI: 1.22, 7.54 I ²= 0% p = 0.02), cardiac complications (OR: 4.33 95% CI: 2.14, 8.77 I ²= 0% p < 0.0001), urinary tract infections (OR: 2.08 95% CI: 1.80, 2.41 I ²= 0% p < 0.00001), and sepsis (OR: 4.95 95% CI: 1.87, 13.08 I ²= 64% p = 0.01) as compared to those with normal albumin.

Conclusion

Hypoalbuminemia is a significant risk factor for complications after spinal degenerative and deformity surgeries. Research is also needed on the role of nutritional support in improving outcomes after spinal degenerative and deformity surgeries.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022340024.

The Utility of Closed Incision Negative Pressure Wound Therapy following Spinal Fusion: A Systematic Review and Meta-Analysis

OBJECTIVES

To determine if closed incision negative pressure wound therapy (ciNPWT) decreases surgical site infection (SSI) or wound dehiscence following spinal fusion.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic review and meta-analysis was conducted to identify studies utilizing ciNPWT following spinal fusion. Funnel plots and quality scores of the articles were performed to determine if the articles were at risk of bias. Forest plots were conducted to identify the treatment effect of ciNPWT following spinal fusion.

RESULTS

A total of 8 studies comprising 1,061 patients who received ciNPWT or a standard postoperative dressing following spinal fusion were included. The rate of SSI [ciNPWT: 4.49% (95% CI: 2.48, 8.00) vs. control: 11.32% (95% CI: 7.51, 16.70), p=0.0103] was significantly lower for patients treated with ciNPWT. A fixed-effects model showed no significant difference between patients who received ciNWPT or a standard postoperative dressing with respect to requiring reoperations for wound debridement (OR: 1.25, 95% CI: 0.64, 2.41). Additionally, wound dehiscence was not significantly different between the two groups although it was non-significantly lower in ciNWPT-treated patients [ciNPWT: 4.59% (95% CI: 2.49, 8.31) vs control: 7.48% (95% CI: 4.38, 12.47), p=0.23].

CONCLUSION

Closed incision NPWT may reduce the rates of SSI following spinal fusion. The use of ciNWPT may also significantly reduce the burden associated with postoperative wound complications, but the meta-analysis was insufficiently powered to make this association. Additional, studies may identify a subset of patients who benefit from ciNPWT for other wound-related complications.

Surgical site infection in upper extremity fracture: Incidence and prognostic risk factors

Upper extremity fractures (UEF) occurred in about 0.67% of males and females at some point in their lifetime. Surgical treatment has the advantage of good functional recovery, however, the occurrence of surgical site infection (SSI) affects the clinical outcome of operation. Currently, there are few studies focused on SSI of UEF. Consecutive patients with UEF and underwent surgeries from January 2010 to February 2021 were recruited. Demographic data, surgical related variables and laboratory test index of these patients were extracted and collected from the electronic medical records and picture archiving and communication system by well-trained investigators. Receiver operating characteristic (ROC) analysis was performed to detect the optimum cut-off value for continuous variables. Multivariate logistic regression analysis was performed to identify independent risk factors of SSI. In total, 286 patients with a mean age of 44.4 ± 16.6 years were identified for inclusion, 59.8% patients diagnosed with fracture of radius and ulna and 40.2% fractures located in the humerus, closed and open fractures were occurred in 252 and 34 adult patients respectively. 7.3% UEF patients were encountered with SSI, incidence of superficial and deep infection was 6.3% and 1.0%. Open fracture (OR, 8.33; P, .000), operation time longer than 122 minutes (OR, 3.12; P, .036), intraoperative blood loss more than 135 mL (OR, 3.98; P, .009) and albumin (ALB) lower than 40.8 g/L (OR, 3.60; P, .015) were demonstrated as independent risk factors of SSI. Adequate preoperative evaluation, careful intraoperative manipulation, and timely and appropriate postoperative interventions should be formulated to reduce the incidence of SSI in patients with the above perioperative high-risk factors.

Preoperative Malnutrition-Associated Spinal Malalignment with Patient-Reported Outcome Measures in Adult Spinal Deformity Surgery: A 2-Year Follow-Up Study

Introduction

Malnutrition could lead to additional medical complications, and the prognostic nutrition index (PNI) is evaluated to assess the nutritional status of patients. However, the midterm postoperative outcomes of malnutrition in patients with adult spinal deformity (ASD) are unclear. This study aims to investigate postoperative midterm spinal alignment and patients' reported outcome measures (PROMs) in malnourished patients with ASD.

Methods

This study recruited 303 ASD patients who underwent surgery. Adult patients ≥50 years old were categorized into the PNI <50 (L group) and the PNI ≥50 (H group) groups. Demographic data, medical complications, mechanical complications, radiographic parameters, Oswestry Disability Index (ODI), and Scoliosis Research Society-22 (SRS-22) were analyzed.

Results

In this study, 303 patients participated, with 132 and 171 patients in the L and H groups, respectively. Significant differences were noted between the L and H groups in body mass index (22.5 vs. 23.6 kg/m², p=0.011), autoimmune disease (9.8% vs. 2.3%, p=0.005), and total number of medical complications (47.7% vs. 33.3%, p=0.011). The T1 slope was significantly higher in the L group than in the H group preoperatively (36.5 vs. 32.8°, p=0.042). However, no significant differences were noted in mechanical complications, ODI, SRS-22 scores, or radiographic parameters 2 years postoperatively between the L and H groups, except for the sagittal vertical axis (73.1 vs. 55.7 mm, p=0.014).

Conclusions

No significant difference was noted in the incidence of mechanical complications and PROMs 2 years postoperatively. Malnourished status was related to medical complications and global malalignment. However, good surgical outcomes can be expected even for malnourished patients.

Prognostic values of the C-reactive protein to albumin ratio and prognostic nutritional index in carotid endarterectomy patients

OBJECTIVES

C-reactive protein to albumin ratio (CAR) and prognostic nutritional index (PNI) are novel parameters with proven prognostic importance in the postoperative outcomes of coronary and peripheral vascular diseases. In this study, we aimed to evaluate the ability of CAR and PNI to predict major cardiac and cerebrovascular events (MACCE) during the postoperative period of Carotid artery endarterectomy (CEA).

METHODS

A total of 505 carotid endarterectomy patients were retrospectively evaluated. Of 505 patients, 23 patients who died and who experienced myocardial infarction or major neurologic complication in the first 30 days after the operation were included in MACCE group (Group 1). The remaining 482 patients were included in Group 2. Receiver operating characteristics (ROC) curve analysis was used to evaluate preoperative serum albumin value, lymphocytes count, PNI, and CAR to predict the MACCE. The DeLong test was used to compare the area below the curve (AUC) with each of these parameters.

RESULTS

CAR (2.48 ± 1.82 and 1.64 ± 1.37) and CRP (9.98 ± 7.42 and 6.81 ± 5.70) values are statistically higher in Group 1 than in Group 2. PNI (41.59 ± 3.11 and 43.54 ± 4.20) and albumin (40.43 ± 3.15 and 42.35 ± 4.15) values were significantly lower in Group 1 than in Group 2. The accuracy of albumin (AUC: 0.669) in the prediction of MACCE was found to be the highest among CAR (AUC: 0.631), PNI (AUC:0.667), and CRP (AUC:0.631).

CONCLUSION

Preoperative nutritional and inflammatory status is significantly associated with post-operative outcomes. PNI and CAR can be used for preoperative evaluation, as CEA is recommended for patients who have low possibility of having postoperative major adverse events.

Incidence and Risk Factors for Surgical Site Infection after Femoral Neck Fracture Surgery: An Observational Cohort Study of 2218 Patients

Background

Surgical site infection (SSI) was a formidable challenge for surgical management of femoral neck fractures; however, there was a lack of studies with comprehensive variables. We conducted this study to investigate the incidence and risk factors of SSI in elderly patients with femoral neck fractures.

Methods

This was a retrospective study of patients who presented with femoral neck fractures and underwent surgery in our institution between January 2016 and April 2020. All data were collected from a previously validated database. Patients were divided into SSI and non-SSI groups. Univariate and multivariate logistic regression analyses were conducted to identify the risk factors for SSI.

Results

A total of 2218 patients with femoral neck fractures were enrolled in the study, of whom 22 (1%) developed SSI, including 15 (0.7%) superficial and 7 (0.3%) deep SSIs. After multivariable adjustment for confounding factors, patients with and without SSI significantly differ in terms of gender, prolonged time to surgery, CHE < 5 U/L, and injury mechanism.

Conclusions

Our results were helpful for stratification of SSI risk and improved management of hip fracture. Clinicians should be alert to patients with these factors and improve modifiable factors such as preoperative waiting time.

Surgical Apgar Score and Controlling Nutritional Status Score are significant predictors of major complications after cervical spine surgery

Nutritional screening scores, including Controlling Nutritional Status (CONUT) Score and Surgical Apgar Score (SAS), which reflect intraoperative hemodynamics, have been reported to be useful for predicting major postoperative complications in various kinds of surgery. We assessed independent risk factors for major complications after cervical spine surgery using those scoring measurements. We retrospectively reviewed medical records of patients who underwent cervical spine surgery at our institution from 2014 to 2019. Baseline clinical information, including the CONUT Score, and surgical factors, including the SAS, were assessed as risk factors for major postoperative complications. We analyzed 261 patients. Major postoperative complications occurred in 40 cases (15.3%). In the multivariate analysis, SAS (odds ratio [OR], 0.42; P < 0.01), CONUT (OR, 1.39; P < 0.01), and operative time (OR, 1.42; P < 0.01) were significant independent risk factors of major complications. The area under the SAS curve was 0.852 in the receiver operating characteristic curve analysis. Postoperative hospitalization duration was significantly longer in major complications group. Evaluating preoperative nutritional condition and intraoperative hemodynamics with CONUT score and SAS was useful for predicting major postoperative complications of cervical spine surgery. In addition, both scoring measurements are easily calculated, objective evaluations. Perioperative management utilizing those scoring measurements may help prevent them.

Enhanced recovery after surgery pathway: association with lower incidence of wound complications and severe hypoalbuminemia in patients undergoing posterior lumbar fusion surgery

Background

Wound complications are associated with worse satisfaction and additional costs in patients undergoing posterior lumbar fusion (PLF) surgery, and the relationship between enhanced recovery after surgery (ERAS) pathway and wound complications remains poorly characterized.

Methods

In this retrospective single-center study, we compared 530 patients receiving ERAS pathway care with previous 530 patients in non-ERAS group. The primary aim of our study was to identify the relationship between the ERAS program and the incidence of postoperative wound-related complications and other complications following PLF surgery; other outcomes included the length of stay (LOS), 90-day hospital and rehabilitation center readmission.

Results

The average patient age was 65 yr. More patients with old cerebral infarction were in ERAS group (p < 0.01), and other demographics and comorbidities were similar between groups. Patients in the ERAS group had a lower incidence of postoperative wound-related complications than the non-ERAS group (12.4 vs. 17.8%, p = 0.02). The non-ERAS group had a significantly higher rate of wound dehiscence or poor wound healing (6% vs. 3%, p = 0.02). ERAS group had a lower incidence of severe postoperative hypoalbuminemia (serum albumin less than 30 g/L) (15.8% vs. 9.0% p < 0.01). Additionally, ERAS patients had shorter postoperative LOS (8.0 ± 1.5 vs. 9.5 ± 1.7, p < 0.01), lower rate of readmission within 90 days (1.9% vs. 6.4%, p < 0.01) and discharge to rehabilitation center (4.2% vs. 1.0%, p < 0.01).

Conclusion

ERAS pathway might help decrease the rates of postoperative wound complications and severe hypoalbuminemia following PLF surgery; additionally, it demonstrated that ERAS pathway was also associated with shorter LOS and lower rate of readmissions within 90 days.

Postoperative Management Strategy of Surgical Site Infection following Lumbar Dynesys Dynamic Internal Fixation

Aim

To research the incidence of surgical site infection (SSI) following lumbar Dynesys dynamic internal fixation and its management strategy.

Methods

We retrospectively analyzed all cases of lumbar Dynesys dynamic internal fixation performed from January 2010 to December 2019, and the data from patients with SSI were collected. The observational indicators included the incidence of SSI, general information of the patients, surgical details, inflammatory indicators, pathogenic bacteria, and treatment. SSI was defined as both early infection and delayed infection, and the cases were divided into Groups A and B, respectively. The relevant indicators and treatment were compared between the two groups.

Results

A total of 1125 cases of lumbar Dynesys dynamic internal fixation were followed up. Twenty-five cases of SSI occurred, and the incidence of SSI was 2.22% (25/1125). There were 14 cases of early infection (1.24%) and 11 cases of delayed infection (0.98%). Fourteen cases of early infection occurred 12.3 ± 8.3 days postoperatively (3–30), and 11 cases of delayed infection occurred 33.3 ± 18.9 months postoperatively (3–62). The inflammatory indicators of Group A were significantly higher than those of Group B (all P < 0.05), except for procalcitonin. The main infection site in Group A was located on the skin and subcutaneous tissue and around the internal instrument, while the main infection site in Group B was around the internal instrument. The main treatment for Group A was debridement and implant replacement, and the main treatment for Group B was implant removal. Summary. The incidence of SSI following lumbar Dynesys dynamic internal fixation was 2.22%, the incidence of early SSI was 1.24%, and the incidence of delayed SSI was 0.98%. If the main infection site of early infection is in the incision, debridement should be the main treatment method; if the infection site is around the internal fixation, implant replacement is recommended on the basis of debridement. Once delayed infection is diagnosed, implant removal is suggested.

Development and Validation of a Nomogram for Predicting Albumin Transfusion After Spinal Tuberculosis Surgery: Based on Propensity Score Matching Analysis

BACKGROUND

There have been few literature reports on the use of perioperative parameters to predict the risk of albumin transfusion after spinal tuberculosis surgery based on the application of nomogram and propensity score matching (PSM) analysis.

OBJECTIVE

The purpose was to predict the risk of albumin transfusion after spinal tuberculosis surgery based on a combination of PSM and nomogram.

METHODS

The clinical data of the patients were collected in our hospital, including preoperative clinical data, preoperative laboratory tests, and postoperative clinical data. All data were divided into 2 groups, including the albumin transfusion group and the non-albumin transfusion group. The PSM analysis was used to adjust the baseline data of the 2 groups. The nomogram was further constructed. The practicability and predictive ability of the model were evaluated.

RESULTS

A total of 494 cases were collected in this article; 102 pairs by PSM analysis were used to construct the nomogram. There were statistical differences in surgical approach, aspartate aminotransferase/alanine aminotransferase levels, drainage, and kyphosis by logistic analysis, and these parameters were included in the construction of the nomogram. The C-index of the prediction model was 0.734. The area under the curve was 0.73 and the net benefit was between 0.13 and 0.99. The calculated C-index was 0.71 by the internal verification method.

CONCLUSIONS

The PSM analysis had a good matching effect and the nomogram had a good predictive ability. Surgical approach, aspartate aminotransferase/alanine aminotransferase levels, drainage, and kyphosis might be predictors of albumin transfusion after spinal tuberculosis surgery.

Preoperative prognostic nutritional index is useful factor for predicting postoperative delirium after primary total joint arthroplasty

Background

Postoperative delirium (PD), as an acute brain failure, is widely reported as a very common postoperative complication, and it is closely associated with increased morbidity and mortality. Recently, malnutrition is reported as one of the risk factors for PD. The prognostic nutritional index (PNI) is a simple method for nutritional evaluation. However, few studies have discussed the effectiveness of PNI as a nutritional assessment in predicting PD after primary total joint arthroplasty (TJA). The aim of this study is to investigate potential risk factors including PNI for PD following primary TJA.

Methods

A retrospective analysis of 994 patients was performed to identify risk factors associated with PD after primary TJA by using univariate and multivariate analyses. A receiver operating characteristic curve and the area under the curve were applied to evaluate the significant results of the multivariate analysis and the optimal cutoff value (CV).

Results

Postoperatively, sixty-seven patients (67/994, 6.7 %) experienced PD. Univariate analysis demonstrated that operative time, duration of anesthesia, age, hypertension, serum albumin, and PNI differed between the PD and non-PD groups (P < 0.05). Multivariate logistic regression analysis showed that the preoperative PNI (odds ratio [OR]: 0.908; 95 % confidence interval [CI]: 0.840–0.983; CV: 47.05), age of patients (OR: 1.055; 95 % CI: 1.024–1.087; CV: 73.5 years), and hypertension (OR: 1.798; 95 % CI: 1.047–3.086), were independently associated with PD (P < 0.05).

Conclusions

A low preoperative PNI associated with malnutrition was demonstrated to be an independent risk factor for PD following primary TJA. Patients with preoperative low PNI should be cautioned and provided with adequate nutritional intervention to reduce postoperative PD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04626-6.